Laserfiche WebLink
I: APPLICATIOW PERMIT {: SAN JOAQUIN LOCAL HEALTH DIS <br /> - r• UNDERGROORD TANK r 1601 E HAlELTON AVE., STOCKIORA <br /> X: CLOSURE OR ABANDONMENT F Telephone (209) 466-3420 t: <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> CAC 000186463 PROJECT CONTACT I TELEPHONE 1 Martin Thorpe <br /> EPA SITE t C <br /> _ ( — __ (209) 462-4581____ <br /> F FACILITY NAME KBTS PHONE 1 (209) 823-3897 — <br /> A _— ---- <br /> C ADDRESS 9901 Woodward Road, Ripon, CA <br /> I - -- <br /> L CROSS STREET Moffat Road <br /> 1 <br /> T OYNER/DPERATORKBTS PHONE t (209) 823-3897 <br /> Y <br /> C CONTRACTOR NAME JIM THORPE OIL, INC. PHONE 1 (209) 462-4581 <br /> G -- — <br /> N CONTRACTOR ADDRESS 351 N. Beckman Road CA LIC 1 495699 CLASS A, Haz. <br /> T -- -- <br /> R INSURER on file WORK.COMP.1 on file <br /> A2 <br /> C FIRE DISTRICT- V,E5;� `f A� PERMIT 1/INSPTR—� <br /> T —•- <br /> 0 LAIORATORY NAME Canonie Environmental PHONE 1 (209) 983-1340 <br /> R --- <br /> SAMPLING FIRM* same SAMPLING METHOD See ;5 on tank removal plan <br /> TANK ID 1 TANK SIZE CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIDUSL <br /> T _ / <br /> A 39- .�1 300 to 500 Waste Oil <br /> N 39 ,lyl-� J ___ 300 to 500 Waste <br /> K 39 <br /> --------------------------- <br /> 39 <br /> --------------------------- <br /> 39 <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P ____ APPROVED __ APPROVED WITH CONDITIONS DISAPPROVED <br /> L (SEE ATTACHMENT WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME ----------------------------- --- - DATE <br /> ------------------------------ <br /> N <br /> APPLICANT RUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF THE BAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S S16MATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> IM THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SMALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECON <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING; 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL F LEAST 48 HOURS IN ADVANCE <br /> SIGNED___ <br /> sff{fff-fV-{-fif-c-f-feu----Pf-frf-e-f-{s-fif-f-d-tef-nfftfafffffff{fD{A{fTEff{{{6f/ff2{0ff/{8{9 <br /> -------- _ ___ -------{f- <br /> -f-{-f{-{--f-f-{-{-{- <br /> OFFICf_ ! -EM J IZ J <br /> PS 1 I CO 1 LOC CODE DIST CODE AMOU DUE AMOUNT RCVD CKI/!!!!L RCVD BY DATE RCVD I PERMIT t <br />